|Year : 2016 | Volume
| Issue : 1 | Page : 1-5
Re-humanizing “high-tech, no touch” medicine: Narrative medicine and cinemeducation perspectives
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||2-Jun-2016|
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. Re-humanizing “high-tech, no touch” medicine: Narrative medicine and cinemeducation perspectives. Arch Med Health Sci 2016;4:1-5
We have lost something of the art of medicine in a headlong rush to embrace the science
– Bill Kirkup
In this healing profession that is oriented on relationship-centered care, I would unequivocally state that one of the quintessential virtues of a clinician (healer) and his art of doctoring is the deep conviction and interest in humanity. Sadly, this is not the reality in today's hi-tech medicine since the art of doctoring and healing; the interest in medical humanities and the healing effect of the Quantum touch is virtually lost. This humanistic attrition coupled with the unrelentless steadfast rush for empiric logicoscientific evidence-based medicine (EBM), in my opinion, has certainly and inevitably emptied the “art, heart and soul” of medicine to a dehumanized system of health-care enterprise. I would call this transformative change in the landscape of the modern health-care enterprise as “hi-tech, no touch medicine.” This attrition in the humanistic soul of medicine is also reflected in medical school training where there has been no emphasis on cracking the hidden curriculum and teaching humanities. I call for a renaissance for re-humanizing “high tech, no touch” medicine to a humane trajectory of “high-tech, high-touch” medicine in accordance with our ancient Indian heritage of the Department of Medicine at Nalanda University where the process of selecting a medical student for learning the art of healing the ailing has long been propounded.
I am not a skeptic of the tremendous leaps and advances in modern medicine, but an optimistic pessimist, recognizing the “glass of our medical school training” as half empty since we are certainly witnessing an erosion of Oslerian medicine to the current dehumanized, disempathetic, uncompassionate clinical and the professional encounters characterized by a distinct “social-disconnectedness,” a “detached concern,” and “heartlessness.” I would term this paradigm shift of our medical educational system as a deadly satire by forsaking the study of humanities. It is indeed paradoxical to me that as first-year medical students, our first “touch with humans” are the cadavers in the anatomy dissection halls, rather than an integration to “medical humanities,” learning the subtleties of patient-centered encounters which to my mind would nurture and rekindle the innate human prosocial qualities such as empathy, compassion, and altruism in aspiring medical trainees. Albeit the perspective of the social neuroscience of Homo sapiens that our Hominid species is wired for “emotionally-inclusive care” as “homo empatheticus,” it is regretful to realize that hi-tech evolution of modern medicine has emptied itself of the art of doctoring, caring and the therapeutic and empathetic bond between the doctor and patient relationship. To the contrary, we are witnessing an increasingly hi-tech medical world, changing climate of medical education theory and practice, evolving nature of health-care delivery, the emergence of electronic medical records, computers on wheels, computer terminals in nursing stations, undue reliance on investigation data, increasing attention to the computer screen, and smart phones.
Professional encounter now occurs where doctors distance from their patients and from the “listening” (“listening to,” and “listening with” the patient) and “narrative” aspects of the physician-patient relationship-centered care only to be substituted by surrogate hi-tech armamentarium. I would say that this “hi-tech, no-touch” encounter has inevitably led to the lack of clinical competence (hyposkillia) and humanism (compassion, altruism, empathy, and professionalism) with the resultant “dehumanization” of modern medicine.
It is sad to note that the culture of medical schools today, a cradle for nurturing and fostering professionalism and humanism, is far from ideal. In Indian medical schools, we need role model teachers, master clinicians, and educators in the reincarnation of the Oslerian spirit. Such leaders and torchbearers will have the vision to introduce innovative curriculum strategies to revamp medical education. This would be feasible by cracking the hidden curriculum to indoctrinate tomorrow's physicians in the art of doctoring and to integrate their “logico-scientific” medical knowledge and clinical competencies with proficiency in humanities. I would reiterate that medicine is a plurality of science and humanitarian principles. By teaching humanities, understanding subtleties of the doctor-patient relationship in the art of doctoring, stress on the Humanistic, Empathetic, Altruistic, and Relationship (HEART)-centered relational dynamics, emotionally inclusive care, and “whole person medicine” the medical students would be able to understand how behavioral empathy and human touch is linked to a greater likelihood of positive therapeutic health outcome as evidenced by faster recovery from disease, higher levels of happiness, and well-being.
Taking cognizance of the dimension of “hi-tech, no-touch” medicine, it is imperative and logical to re-humanize medical education to one of “hi-tech, hi-touch” relationship-centered care. Regular classroom lectures may be an inadequate to teach these difficult issues to medical students, and alternative approaches to evoke insight, teach and learn the humanistic aspects of relationship-centered care is quintessential in the undergraduate curriculum. There must be shifts in thinking to move forward with an action plan in medical schools of innovative teaching-learning methodologies to indoctrinate “hi-touch” humanistic medicine to maintain equipoise between the “science” and “art” of medicine. Science alone without humanism would irrevocably empty medicine of healing, and being an “above the foramen magnum” neurologist I would reiterate hi-touch medicine through the conduit of humanistic behaviorism evokes functional salutogenic mechanisms of the brain that would harness positive healing outcomes.
I would now like to dwell on my passion for two innovative teaching tools, i.e., narrative-based medicine (narrative medicine) and cinemeducation which can reinvigorate young medical students and doctors in training, that in my view, would go a long way forward in an attempt to re-humanizing “high tech, no touch” medicine to “high-tech, hi-touch” medicine. For the intellectual imperialist with EBM mindset, teaching humanities, teaching narrative-based medicine and cinemeducation would be considered as an “alienated subject” in medical schools. On the contrary, I would stress that these are invaluable tools that offer priceless opportunity for medical educators to teach humanistic aspects (teaching professionalism, altruism, compassion, spiritualism, ethics, emotional, psychosocial and relational dynamics of the patient-physician relationship, end-of-life issues) in the clinical physician-patient encounter that would constructively explicate an insight into human illness and in a broader outlook into human condition.
Narrative-based medicine  was a term coined in the year 2000 by Dr. Rita Charon, Professor of Clinical Medicine, and Director of the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons after acknowledging the shortcomings of EBM. I would ascribe “narrative medicine” to refer to the art of doctoring and clinical practice that is enshrined by narrative competence, i.e., the capacity to recognize, honor, metabolize, interpret (through reflective writing) and be moved through humane prosocial virtues of empathy, compassion, altruism, and professionalism  by the personal stories of the patients' and their beloved families and caregivers. The personal stories may be their illness sufferings (pathographies), apprehension, and worries (“What is wrong with me?” “Why did this happen to me?” and “What will become of me?”), the anguish, feelings of vulnerability (pain, suffering, the sense of something just not being right), the experience of caring for them, their recovery from illness, and the fervent hope of a positive healing outcome. Narrative medicine provides insight into respective experiences, unfolds the complex interwoven “stories” in relationship-centered care into “an audible and visible” realm that would have otherwise passed by without notice since they are hard to put down in words. In another words, Narrative medicine dwells on these “unheard” tales during the “up close and personal” relationship-centered care encounter and “bring into conscious existence” of medical students to explore, absorb, and interpret the three dimensions that includes the physician and patient, physician and self, physician and colleagues, and physicians and society.
In my formative years, narrative-oriented physician-patient relations have always been a vital part of medicine where we did play a role in unfolding the interwoven story of patient-centered care. However, with the evolution of modern medicine and EBM, patient narratives were neglected during medical training and were substituted by more scientific hi-tech objective tangible patient investigation oriented reports and findings. Such scientific facts and findings have led to the neglect on the description of the “life of the illnesses” in our interaction with individual human beings with disease, and a breakdown in patient-oriented, physician-patient communication, and “atrophy of clinical skills” and humane touch (“hi-tech no touch” modern medicine). How many of the young doctors do have the time, emotional willingness for exquisite attention to “listen to” and “listen with” and “honor” patient-illness narratives, pay attention to what they say and how they say it, the gaps and silences, their sobs, their rage and mourning, their facial emotional expressions and body language in addition to the minefield of medical information? As medical students and young doctors in medical schools, are we encouraged to share, write our encounters with patients, our difficulties in ameliorating distressing patient symptoms, our anguish or frustrations in caring for patients, our inability to know what to do in clinical dilemmas, and our sense of “loss,” “defeat,” and “burn-out” when the patient's condition deteriorates despite our best evidence-based care, and our victory when things go well?
These questions of “experiences” that I posed earlier are conventionally not written by doctors in the hospital chart or discussed in ward rounds or seminars. Thus, narrative medicine brings into conscious existence of these experiences through narrative writing and reflective writing that serves as a “humanities platform” for the “developing doctor” in becoming a better doctor with “sufficient humanities” for hi-touch medical and nourishing the humanistic moral enterprise of healthcare. This narrative competence would indoctrinate and inculcate the development of a mindset with respective sensitivity and inner involvement (self-reflection, narrative communication skills, narrative listening skills, all-encompassing attention, empathetic witnessing and understanding, reflective writing, analysis of video- or audio-recorded consultations together in a peer group, cinemeducation) toward meaning-creating processes during the multifaceted medical encounter. Teaching and development of such narrative skills, through the arts and humanities, would certainly re-humanize the biomedical emphasis of science-oriented physician development in our medical schools and enable the physician to practice medicine and the art of doctoring with empathy, reflection, professionalism, and trustworthiness. Narrative competence would not only negate the “social disconnectedness” and “detached concern” of modern doctors but would certainly reinforce the models of biopsychosocial medicine in addition to a healing effect since the expression of emotion can have a cathartic effect (narrative therapy; therapeutic narrative writing).
Another unique and enjoyable narrative medicine approach for the teaching of medical humanities is the role of cinema (cinema seminar-teaching film using full-length movies or selected clips) in the training and education of medical students and residents. Cinemeducation, a term coined in 1994, describes the use of popular film for teaching in medical education. To my mind, cinemeducation in group settings would be conducive for brainstorming, generating meaningful group discussions and debates and sharing processes of a scene or characters in the movie from different experiential perspectives. The enormous emotional power of movies would not only explicate the “hidden” relational dynamics of patient-doctor relationship, psychosocial aspects of medicine and healthcare but provide an opportunity to engage narratives into conscious existence that would teach empathic behaviors, emotional responsivity, self-reflection, compassion, altruism, professionalism and that are otherwise ignored during the medical school training.
It is interesting to note that cinemeducation has played a role in various academic disciplines such as general science, nursing, law, and business education. It has been well grounded in psychiatric education and should not come as a surprise to be used as a teaching tool in medical education. Movies do create a controlled environment where the picture is worth a thousand words that evoke powerful learning experiences through archetypal experiences, and the collective unconscious. The teaching films no doubt would invariably evoke learning from a cognitive and emotional standpoint, but would encourage develop metacognitive strategies (thinking critically about thinking) on a variety of themes such as compassion; family dynamics; families and illness sufferings; mental illness and physical illness; hope; personal values or beliefs; spiritualism, delivering bad and sad news, process of grief and the complexity of human reactions when facing end-of-life situations and palliative care. As medical educators do we need to prescribe selected films that our medical students should compulsorily need to borrow and watch, and to promote group discussion and feedback sessions?
In my journey through hi-touch medicine, I would recommend certain movies as pedagogical strategies that to my mind, will harness enormous emotional reactions. Such movies would be The Doctor (1991) inspired by Dr. Edward Rosembaum's book titled “A Taste of my Own Medicine: When the Doctor is the Patient,” Patch Adams and Munna Bhai M.B.B.S (humor in medicine, alternative medicine), Gifted Hands (The Ben Carson story-love, loyalty, motivation, dedication, self-directed learning, passion), A Beautiful Mind (a story of schizophrenia), The Awakenings (The Levodopa story, catatonia and epidemic of encephalitis lethargica), Still Alice (bonds, relationships in Alzheimer's disease), One Flew Over the Cuckoo's Nest (mental illness and sanity, dynamics and ethics of mental care and institutionalization, Nurse Ratched as an antithesis to nursing ethics, ECT, psychosurgery); Iris (true story; relationship dynamics and battle with Alzheimer's disease); Shine (portrays mental breakdown by schizoaffective disorder; psychological impact of formative relationships; the way the human spirit to heal); I am Sam (mentally challenged with Autistic spectrum disorder and humanity-themes of love, patience, and devotion; desensitize a society that is already ignorant of the needs of the mentally and physically challenged); Philadelphia (AIDS); Lorenzo's Oil (a relentless mission by parents to search an “alternative” treatment through experimental medicine for their son diagnosed with adrenoleukodystrophy); Stepmom (comprehending death and grief); Concussion (the tenacity of scientific research and research ethics; in pursuit of the truth by Dr. Bennet Omalu, a Nigerian forensic pathologist to describe chronic traumatic encephalopathy in American National Football League Players); Infinitely Polar Bear (Mental illness-Manic depressive psychosis); The Diving Bell and the Butterfly (true story of Elle editor Jean-Dominique Bauby who suffers from “locked in syndrome”); Away From Her (institutionalization and Alzheimer's disease); and The Theory of Everything (relationship between the famous physicist Stephen Hawking and his wife) to name just a few.
In the end, while I certainly acknowledge the marvels of modern medicine and being a neurologist, I have been fascinated by the tremendous progress made in this “century of the brain.” However, my soul searching question has been: Enshrined in our doctrine of reductionist materialism coupled with our intellectual imperialism, will the progress in neuroscience and neurotechnology evolve into a “sciences without humanity” and leave “no room for God?” Through rapidly evolving disciplines of Neuro cybernetic prostheses, Intelligence-Cognitive Robotic Systems, brain-machine
interfaces, futuristic telepathy helmets, Brain Nanotechnology revolution and Nanobot Neural Implant, there is a now an evolution of Homo sapiens to Homo hybridus, Robotus primus; Homo cyberneticus; Homo machinus all in a race to create “God like” superintelligence. An Italian neurosurgeon Sergio Canavero has made the impossible of today a possibility of tomorrow, i.e., a head-brain transplant in a monkey this year. The head transplantation with spinal linkage venture is being planned by Sergio Canavero for a 31-year-old Russian computer scientist, Valery Spriridonov, who has Spinal muscular atrophy (born with Werdnig-Hoffman disease) by the end of 2017. My next pragmatic question on this evolution in neurocentricism will be centered on the concern for ethical, legal, and social implications of neurosciences research. Would this evolution of “medical sciences without humanity” be viewed as giant leap to solve previously incurable disorders or would this threat of science without humanity be reminiscent of Mary Shelley's 1994 Frankenstein film?
Various studies and reports have indeed opened medicine's Pandora's Box, for example “Error in Medicine” by Leape published in the Journal of the American Medical Association, 1994 and another mind-boggling article titled “Death by Medicine” by Null et al. In this respect, I would wish to reflect on the “limits of science” by two quotes by George Bernard Shaw (1856-1950) “Science becomes dangerous only when it imagines that it has reached its goal” and “Science is always wrong. It never solves a problem without creating ten more” as “food for thought.” Perhaps the downfall of modern “hi-tech, no touch” medicine could be termed as “Euboxic medicine” and certainly this trajectory of medicine, in my experience, will not provide answers to the ills of society. Instead reorienting
ourselves to being “homo empatheticus” and re invigorating humanistic medicine will be the need of the hour.
To see light at the end of the tunnel, I would undeniably underscore the relevance for teaching humanities (narrative medicine; cinemeducation) to re-humanize and restore the humanistic soul of medicine. I firmly believe that “teaching of humanities” would certainly bridge the schism between the “heart, soul and art” of doctoring (“hi-touch” medicine) and the empirical science of EBM (“hi-tech” medicine). Narrative-based medicine would indeed serve as a model for the development of self-awareness, altruism, compassion, empathy, professionalism and physician-society public trustworthiness for an effective health care enterprise.
In conclusion, are we as medical educators “polishing” medical trainees from the “outside” with technocratic medicine and not from the humanistic “sanctum sanctorum” for whole person positive healing outcomes? In this respect, I would say that the challenges facing medical education of the 21st century are truly enormous. The need of the hour would be humanistic reforms of a transformational nature to be modelled within the internal culture and social milieu of medical schools. Akin to the story of “The Parrot's Tale/Training” by Rabindranath Tagore published in 1918, we as medical educators should not throttle and snuff out the innate qualities of the bird (medical students) by giving undue importance to the golden cage, its architecture, its grandeur, envisioning a charade of educational reforms by neglecting the humanistic soul and art of medicine, instead be citadels for the training of HEART-centered doctors (hi-touch medicine) as the way forward to re-humanize the current 21st century medical practice.
Quotes to Honor Narratives
Their story, yours and mine — it's what we carry
With us on this trip we take, and we owe it to each
Other to respect our stories and learn from them.
–William Carlos Williams, 1883-1963, physician and poet
Medicine is to be learned only by experience; it is not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and to know that by practice alone you can become expert. Medicine is learnt by the bedside and not in classroom. Let not your conceptions of the manifestations of disease come from words heard in the lecture room or in a book. See and then reason and control. But see first.
A patient saw a physician for the first time. The physician wanted to learn everything about the new patient, and listened attentively without interruption. The patient paused after a while and wept. When asked why, “No one let me do this before,” was the response.
| References|| |
Charon R. The patient-physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA 2001;286:1897-902.
Alexander M. Cinemeducation: An innovative approach to teaching multicultural diversity in medicine. Ann Behav Sci Med Educ 1995;2:23-8.
Self DJ, Baldwin DC. Teaching medical humanities through film discussions. J Med Humanit 1990;11:23-9.
Alexander M. The doctor: A seminal video for cinemeducation. Fam Med 2002;34:92-4.